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Practice nurse-led diabetic care needed to improve outcomes

Giving patients with type 2 diabetes more time with practice nurses leads to earlier insulin uptake and better outcomes, a BMJ published study has shown.

A team of researchers, headed up by John Furler from the University of Melbourne, tested the ‘Stepping Up’ care model which enables practice nurses to lead on insulin treatment initiation as part of routine care.

Under the model, practice nurses are trained and mentored by a registered nurse qualified as a certified diabetes educator (CDE).

The findings

The study examined 266 diabetic patients, comparing those given practice nurse consultations as part of the Stepping Up model with patients receiving usual care.

The new model was shown to increase insulin initiation rates in primary care from 22% to 70%.

A year later,the patients treated under the new model had significantly better HbA1c levels, associated with lower rates of kidney and eye disease, compared to the control group.

Barriers to treatment

Despite evidence that early adoption of insulin treatment among type 2 diabetic patients improves long-term outcomes, the study found that ‘insulin initiation is often delayed, particularly in primary care, because of barriers in clinical practice.’

Dr Furler told Nursing in Practice that the barriers can include a lack of confidence in insulin initiation guidelines by professionals and concerns about patients suffering hypoglycaemia.

At the patient level, the barriers include fear of needles, fear of hypoglycaemia, and fear of failure, he said.

The study also examined the overall practice system and identified anuncertainty about whose role it was to initiate discussions about insulin uptake with patients.

‘In fact patients were happy to work with any of the health professionals involved’, Dr Furler said.

The study also found that often there was no in-practice system in place for delegating the work, which can be quite ‘intensive and systematic’.

Practice redesign

The intervention suggested practices address these barriers by:

Developing simple clinical protocols

Clarifying that appropriately supported nurses should initiate the discussion

Supporting a pathway within the practice to allocate the work to the practice nurse with CDE mentoring and GP support and review.

‘With appropriate support and redesign of the practice system, insulin initiation can become part of routine diabetes management in primary care, obviating the need to refer to specialist services with geographical, cost, and accessibility barriers,’ the researchers said.